Getting Ahead Application
Email address *
Name (First & Last) *
Date of Birth *
MM
/
DD
/
YYYY
Phone Number *
Street Address *
City, State, Zip *
Highest Grade Level Completed *
Current Income Source *
Required
Place of Employment
What is your monthly income amount? *
Marital Status *
Spouse's name
Please list the name(s) of your child(ren) and ages
BENEFITS: PLEASE CHECK ALL PUBLIC ASSISTANCE/SERVICES YOUR FAMILY CURRENTLY RECEIVES: *
Required
PLACE A CHECK NEXT TO THE AREAS WHERE YOU ARE EXPERIENCING DIFFICULTIES: *
Required
ARE YOU CURRENTLY IN A STATE OF CRISIS? (i.e. HOMELESS, DOMESTIC VIOLENCE SITUATION, UNTREATED DRUG/ALCOHOL ABUSE, ETC.) *
ARE YOU CURRENTLY ON PAROLE OR PROBATION? (THIS WILL NOT AUTOMATICALLY DISQUALIFY YOU FROM THE PROGRAM) *
PLEASE PROVIDE A BRIEF DESCRIPTION OF YOUR CURRENT STRENGTHS/BARRIERS: *
Please check the following if you agree *
Required
PLEASE SELECT THE APPROPRIATE BOX STATING THAT YOU UNDERSTAND THAT YOU ARE APPLYING FOR ADMISSION INTO GETTING AHEAD. COMPLETION OF THIS APPLICATION DOES NOT GUARANTEE THAT YOU WILL BE ACCEPTED INTO THE PROGRAM. EVALUATION OF APPLICATIONS WILL BE DETERMINED AFTER AN INTERVIEW HAS BEEN CONDUCTED. IF YOUR CONTACT INFORMATION CHANGES WHILE WAITING FOR ACCEPTANCE INTO GETTING AHEAD, PLEASE NOTIFY OUR OFFICE SO THAT WE MAY UPDATE YOUR RECORDS. UNTIL YOU HAVE OFFICIALLY RECEIVED A LETTER OF ACCEPTANCE FROM COMMON HEART, IT IS YOUR RESPONSIBILITY TO MAKE SURE THAT YOUR CONTACT INFORMATION ON FILE REMAINS CURRENT. *
Thank you for your interest in Getting Ahead Ahead! Someone will be in touch with you soon. If you have any questions please call 704-218-9060.
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